Provider Demographics
NPI:1215967054
Name:KHODAVERDIAN, ANOUSH ANN (MD)
Entity type:Individual
Prefix:
First Name:ANOUSH
Middle Name:ANN
Last Name:KHODAVERDIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:ANOUSH
Other - Middle Name:ANN
Other - Last Name:GORJIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:777 N. SHEPHERD AVENUE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720
Mailing Address - Country:US
Mailing Address - Phone:559-433-1723
Mailing Address - Fax:
Practice Address - Street 1:6327 N FRESNO ST
Practice Address - Street 2:SUITE 108
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5236
Practice Address - Country:US
Practice Address - Phone:559-440-0110
Practice Address - Fax:559-440-0401
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0A437870208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000A437870Medicaid
CA0000A437870Medicaid